1548336506 NPI number — DR. MOSE CLINTON THORNTON D.P.M.

Table of content: DR. MOSE CLINTON THORNTON D.P.M. (NPI 1548336506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548336506 NPI number — DR. MOSE CLINTON THORNTON D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THORNTON
Provider First Name:
MOSE
Provider Middle Name:
CLINTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THORNTON
Provider Other First Name:
M.
Provider Other Middle Name:
CLINT
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.P.M.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1548336506
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 29TH ST STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94609-3581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-835-3338
Provider Business Mailing Address Fax Number:
510-835-2127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 29TH ST STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94609-3581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-835-3338
Provider Business Practice Location Address Fax Number:
510-835-2127
Provider Enumeration Date:
11/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  E3553 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)